The socio-political situation in Pakistan only seems to be getting worse with each passing day. With political instability and social injustice at an all-time high and appearing to rise only exponentially in the near future, perhaps this is the right time to ask: are we even prepared to talk about mental health in Pakistan? If yes, how and where do we start?
The primary concern for all of us boils down to one area: the system – the infrastructure set in place. However, how does one begin to build when the foundation itself is very shaky? In situations where the building blocks themselves are disorganised, misshapen, and (in this case) fragmented, we need to start from scratch. In regard to the foundation of mental health, few of us are aware that our country possesses a Mental Health Ordinance (MHO). Before I dissect our MHO and its subsequent counterparts, let me shed some light on what mental health laws entail so we are better able to understand what impact the lack of one can have on a country.
Mental health laws are pieces of legislation that are designed to include an assortment of topics that pertain to people with a mental health illness and those who care for them (extending from loved ones to the government). It includes but is not limited to their right to fair treatment/care, but also access to their property, employment, privacy, insurance, education, etc. To put it simply, it guarantees a person with a mental health illness that they would not be treated unfairly on the basis of an illness or diagnosis. It seems unwise to be comparing our country’s legislation to that of others; however, the comparison might alert us to where we stand in terms of mental health reform relative to other low-income nations.
The World Mental Health report conducted in 2022 by the World Health Organisation (WHO) carried out a global comparison to assess which countries were implementing adequate standards of care for mental health. Countries with low-income levels reported the following statistics: 83% had a policy/plan, out of which 45% had a fully compliant policy/plan. From these, only 3% of the countries implemented the fully compliant policy/plan. It would not surprise one to know that Pakistan does not belong to the 3% and has a rather broken history of mental health acts (MHAs).
After Pakistan’s independence in 1947, we implemented the pre-colonial Lunacy Act of 1912 which was challenged by several individuals and so the Mental Health Act of 2001 was formed. This emphasised patient care in some respects (proactive prevention, treatment, access to care, involuntary care, power of attorney, responsibility of court, etc.). However, after the 18th amendment in 2010, health was devolved to each provincial government. Provinces passed their own laws subsequently: Sindh passed its MHA in 2013 which was amended in 2015; Punjab largely retained the federal MHO in 2014; Khyber Pakhtunkhwa (KP) formed their MHA in 2017; Balochistan created their MHA in 2019, and Gilgit-Baltistan does not yet possess one. These statistics and their formation (let alone their implementation) show us the unfortunate state of mental healthcare within Pakistan which demands a sustainable solution.
This is not to say that some of our provinces have not attempted to bring some positive change by including provisions within their MHAs that cater to psychiatric facilities, separate units, and community-based mental health services. Sindh has aimed to address some of the mental health concerns such as admission criteria and treatment for people attempting suicide while KP has also attempted to highlight the need for training for healthcare workers alongside putting emphasis on psychosocial support and rehabilitation. However, it does not seem to be enough when one considers how our nation moves on a population level when listing out individual consent, family care, allocation of assets, and right to treatment.
Our MHAs offer a lot of power to the court in a country where we cannot yet monitor our own government and abuse of power (which in this case can be abused within involuntary confinement, stay at hospitals, stripping of assets and resources, etc.). Alongside, a substantial amount of healthcare in Pakistan is catered by the private sector, whose management is not governed by our MHAs and relies solely on the caregiver. We have also not listed any attempts or suggestions at integrating MHAs within the current health funding. All this is bolstered by the fact that we do not possess even the basic infrastructure (mental health facilities, trained staff, post-treatment guidelines) within Pakistan – the ones that do exist would be deemed unlawful and categorised into human rights violation. Alongside, we have also not accounted for the cultural sensitivity within Pakistan where populations carry certain spiritual and cultural beliefs regarding mental health.
Highlighting a small section of the issues that we face with our mental health legislation demands the questions: how and where do we start? Should we attempt to gather an adequate number of trained and experienced healthcare professionals (psychiatrists, psychologists, nurses, pharmacologists, etc.) from each province and attempt to draft a skeleton for a new patient-centric MHA that is not as obsolete as the current MHO that guides them? Then, do we form a board/committee within the healthcare side of each provincial government that will edit the devised MHA skeleton to fit the provincial demands and resources? What do we do when there are no resources and no trained staff? Do we then begin to generate educational courses that train staff, or do we rely on international help? In a country where the disparity is managed (and dare I say, maintained) through charity, do we form an independent private non-profit organization that attempts to create these solutions and offers consolations to the governments? Do we fall back into the cycle of relying on external donations to aid this crisis? What do we do when there is no clear question of where power is held and how the common man can attempt to plea to it in order to gain some form of basic right? Do we just pray?
As I say, I do not have answers to these questions, and I do not have implementable solutions. All I do know is that when something is barely functioning and falling apart at the slightest of movement, then it is time to perhaps deconstruct and rebuild it all over with a better blueprint and plan. In our case, it appears we need to start from our MHAs, which might allow us to create stunning architecture if we find a miracle to upright what has been uprooted so callously.